Provider Demographics
NPI:1063867026
Name:WHITCOMB, JONNIE (LMT)
Entity Type:Individual
Prefix:
First Name:JONNIE
Middle Name:
Last Name:WHITCOMB
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20474 JACKLIGHT LN
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3074
Mailing Address - Country:US
Mailing Address - Phone:541-350-5431
Mailing Address - Fax:
Practice Address - Street 1:1843 NE 3RD ST STE 2
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3816
Practice Address - Country:US
Practice Address - Phone:541-350-5431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-27
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15718171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor